Phalloplasty is a complex reconstructive procedure that creates a neophallus—an anatomically and sensorially functional penis—using tissue transferred from donor sites. Performed most often as part of gender-affirming surgery for transgender men and nonbinary individuals or to address congenital anomalies and traumatic injuries, phalloplasty restores both form and function. By harvesting vascularized tissue flaps from the radial forearm, anterolateral thigh, or other donor areas, surgeons can sculpt a phallus with integrated urethra, sensory nerve coaptation, and the potential for erectile devices. This surgery demands meticulous planning, a multidisciplinary team, and careful postoperative care to optimize outcomes and minimize complications.
Indications and Candidate Evaluation
Phalloplasty candidates include transgender men seeking gender-affirming genital reconstruction, individuals born with micropenis or penile agenesis, and patients who have suffered penile loss due to trauma or cancer. During the consultation, the care team reviews medical and surgical history, examines donor-site suitability, and evaluates vascular and nerve anatomy. Clear discussion of goals—regarding length, girth, urinary function, sensation, and future prosthesis use—is crucial. Psychological support and informed consent address the multi-stage nature of surgery, potential scarring, and the extended recovery timeline.
Donor-Site Flap Options
Radial Forearm Free Flap
The radial forearm free flap remains the gold standard due to its thin, pliable skin and reliable vascular pedicle. A flap measuring 12–14 cm wide is harvested from the nondominant forearm, with sensory and motor nerves coapted to recipient nerves for tactile and erogenous sensation. The tubularized flap forms both the penile shaft and neourethra. Donor-site closure requires a skin graft, leaving a visible forearm scar that many patients accept in exchange for superior functional outcomes.
Anterolateral Thigh (ALT) Flap
The ALT flap uses tissue from the lateral thigh, offering larger surface area and minimal donor-site morbidity. Although the skin is thicker—sometimes necessitating flap thinning—this option spares the forearm and conceals scarring under clothing. Sensory nerve coaptation is achieved via the lateral femoral cutaneous nerve. The ALT flap accommodates future prosthesis placement without compromising shaft contour.
Other Flap Techniques
Alternate methods—such as latissimus dorsi or abdominal flaps—are reserved for cases where forearm or thigh tissue is unsuitable. These require microsurgical expertise to ensure reliable blood supply and adequate sensory potential.
Urethral Lengthening and Integration
Creating a functional urethra is pivotal for standing micturition. Surgeons often employ a tube-within-a-tube design, where the inner flap surface is tubularized to form the neourethra and the outer surface constitutes the penile shaft. Anastomosis to the native urethral stump at the perineum ensures continuity. A suprapubic catheter diverts urine during healing, while a urethral stent supports the new channel. Catheter removal and voiding trials begin four to six weeks after surgery once healing and leak testing confirm integrity.
Sensation and Erogenous Potential
Restoring sensation involves microsurgical nerve coaptation. The dorsal nerve of the clitoris or ilioinguinal nerve is connected to sensory nerves harvested with the flap—such as the medial antebrachial cutaneous nerve. Over months, axonal regeneration yields tactile and erogenous sensitivity. Sensation may localize based on donor-site nerve distribution, and ongoing research seeks to enhance these outcomes.
Incorporating Penile Prostheses
Since phalloplasty flaps lack native erectile tissue, many patients opt for a penile prosthesis—either malleable rods or inflatable devices—once healing and sensation allow. Inflatable implants consist of cylinders, a scrotal pump, and an abdominal reservoir, providing natural rigidity and flaccidity. Malleable implants use bendable rods for simpler operation. Prosthesis insertion typically follows six to twelve months after the initial phalloplasty, allowing flap maturation and vascular stabilization.
Surgical Stages and Timeline
Phalloplasty unfolds through multiple coordinated phases. Initially, the chosen flap is harvested and sculpted into a neophallus, while native urethral lengthening occurs concurrently. Donor-site closure—using skin grafts or primary closure—follows, managed by reconstructive specialists. Microsurgical anastomosis then connects the flap’s blood vessels to recipient vessels in the groin or perineum. Subsequent procedures refine the neourethra, adjust the perineal-penile junction, and perform nerve coaptation when not done initially. After adequate healing and sensory development, a penile prosthesis may be placed to enable rigidity. Each phase requires weeks to months of recovery before progressing to the next.
Postoperative Care and Recovery
Hospital stays typically last five to ten days after free-flap procedures, with close monitoring of flap perfusion via Doppler and clinical assessments. Pain management uses multimodal analgesia, including nerve blocks and oral medications. Early mobilization—beginning with transfers and ambulation—reduces thromboembolic risk. Specialized wound care teams manage flap and donor-site dressings. Catheter and stent care, sitz baths, and scar management begin immediately. Psychological and peer support resources aid emotional recovery.
Functional and Aesthetic Outcomes
Long-term studies report high satisfaction with both urinary and sexual function. Successful neourethra integration allows standing urination, and sensation evolves over six to twelve months, yielding tactile and erogenous response. Prosthesis use enables penetrative intercourse. Aesthetic outcomes—evaluated by phallus length, girth, glans definition, and scar appearance—depend on flap selection and surgical expertise. Minor revisions may address contour irregularities or optimize cosmetic appearance.
Risks and Complications
Phalloplasty carries significant risks, including partial or complete flap loss, urethral fistula or stricture, infection, and wound breakdown. Flap necrosis rates range from 1–5 percent; meticulous microsurgical technique and postoperative monitoring are essential. Urethral complications occur in up to 30 percent of cases and often require surgical correction. Donor-site morbidity—such as delayed healing, sensory changes, and visible scarring—must be managed proactively. Comprehensive preoperative counseling and coordinated multidisciplinary care mitigate these challenges.
Cost Comparison: US vs. Europe vs. UK
Phalloplasty costs reflect its complexity and regional healthcare systems. In the United States, total expenses—including multiple surgeries, hospital stays, anesthesia, and prosthesis—range from USD 75,000 to 100,000. Western European centers typically charge €60,000 to 90,000 EUR, while private UK providers fee between £50,000 and 80,000 GBP. Some public health systems subsidize gender-affirming phalloplasty, reducing out-of-pocket costs for eligible patients. Detailed cost breakdowns and financing plans assist in financial planning.
Frequently Asked Questions
Does phalloplasty get erect?
Without a prosthesis, the neophallus remains flaccid. Inflatable or malleable implants inserted later enable rigidity for intercourse.
Can you pee after phalloplasty?
Yes. Urethral lengthening techniques allow standing micturition once catheter support is removed and healing is complete.
How realistic is phalloplasty?
Modern microsurgical methods provide a neophallus with natural appearance, urinary function, and potential for sensation. Outcomes depend on surgical expertise and patient factors.
Can you still feel pleasure with a phalloplasty?
With successful nerve coaptation, patients experience tactile and erogenous sensation along the neophallus. Sexual pleasure varies with nerve regeneration and prosthesis use.